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Skilled Nursing Facilities


Billing Requirements

General
  • Indicate “21X”, “22X” or “23X” in type of bill field, which is field 4 for paper claims.
    • First digit – Type of facility (2)
    • Second digit – Bill classification (inpatient - 1, inpatient Medicare B only - 2 or outpatient - 3)
    • Third digit – Frequency (e.g., admit thru discharge claim, etc.)
  • Hospital Swing Bed claims should be billed with the “18X” type of bill and the taxonomy code for the hospital’s swing bed unit.
  • For BlueCare and BlueOptions members, provide the authorization/certification number on the claim. Plan of treatment should not be submitted with claim, unless requested.
  • Submit room and board units to reflect the length of stay minus one unit for the discharge day. Day of discharge or death is not considered a covered day, unless admitted and discharged/deceased on the same day. For example, if a claim is submitted for dates of service 8/1/2010 to 8/7/2010, then the room and board units should be 6 to exclude the day of discharge or death.
  • Refer to contractual reimbursement terms to determine if billing is based on SNF revenue codes or HIPPS RUG codes. Typically only Medicare Advantage provider contracts are negotiated based on the inpatient prospective payment system for SNFs.
  • Florida Blue requires SNF claims are submitted with the 191-194 or 199 revenue codes that represent sub-acute care. Any inpatient SNF claims for Non-BlueMedicare members that do not contain these specific room and board codes will be returned to the provider for appropriate billing.

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Outpatient Therapy Services

Outpatient therapy services are occupational, physical and speech therapy rendered within the SNF. These services must be ordered by the physician and medically necessary.

  • The individual therapist providing physical, occupational or speech therapies may not bill separately for services provided in the SNF.
  • These services must not be billed during the same time frame as an inpatient claim.
  • Outpatient services must be submitted on a separate claim from inpatient services.
  • Outpatient therapy services should be billed with the following revenue codes:
    • 0420 for physical therapy
    • 0430 for occupational therapy
    • 0440 for speech therapy

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Medicare is Primary

If Medicare is primary and Florida Blue or another Blue Plan is secondary, submit the claim with the Medicare Remittance Advice and following information:

BlueMedicare

Please refer to the reimbursement section of the contract to ensure proper billing.
For Providers contracted at a percentage of SNF inpatient prospective payment system should submit the following:
  • Type bill “18X” or “21X”
  • HIPPS RUG codes – units should reflect the number of covered days for each code
  • Revenue code 0022 – charges are not required
  • Additional revenue codes representing services provided can be submitted on the claim
For providers contracted under a Florida Blue inpatient per diem arrangement should submit the following:
  • Type bill “18X” or “21X”
  • Revenue codes 191-194 or 199
  • Units should reflect the number of covered days for the SNF stay
  • Additional revenue codes representing services provided can be submitted on the claim
Note: Medicare Advantage plans replace Medicare coverage; therefore Florida Blue is primary for BlueMedicare HMO and BlueMedicare PPO members.

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Medicare is not Primary

To ensure accurate payment and processing for Florida Blue and other Blue Plan primary claims, which includes MA plans, submit claims with the following information:

Inpatient Care

  • Type of bill (211-214)
  • Revenue code (0191-0194, 0199)

Outpatient Therapy

  • Type of bill (231-234)
  • Revenue codes (0420, 0430, 0440)

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Payment Methodology

Inpatient Payment Methodology

SNF services are reimbursed on an all-inclusive per diem (daily) rate reflecting the level of care rendered.

  • For each day, bill the revenue code (0191-0194, 0199) associated with the actual level of care provided.
  • Bill only one level per day; each higher level includes services provided at the lower care levels as defined in the applicable agreement. Multiple per diem revenue codes can be billed on an individual claim.
  • Payment is based on units identified with the applicable all-inclusive per diem revenue code (1 unit = 1 day).
  • The level of care is determined based on diagnosis, severity of condition and intensity of services. The level will be assigned based on the applicable provider agreement and/or Care Coordination intervention.

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Per Diem Levels

Per diem rates are based on the level of care assigned. Refer to applicable provider agreement for specific terms.

  • Level 1 (Revenue Code 0191)
  • Level 2 (Revenue Code 0192)
  • Level 3 (Revenue Code 0193)
  • Level 4 (Revenue Code 0194)
  • Level 5 (Revenue Code 0199)
  • All per diem rates will include, but may not be limited to the following services:
  • Semi-private room
  • Meals (including special dietary requirements)
  • Skilled nursing care
  • Case management
  • Medication and pharmacy supplies
  • Routine laboratory
  • Routine radiology (except when excluded based on the terms of the agreement)
  • Oxygen services
  • Nutrition services (including enteral feedings)
  • Administration of medications including intramuscular and intravenous services
  • Medical supplies
  • Discharge planning
  • DME (excluding specialized/high cost DME*)
  • Quality assessment and improvement programming
  • Occupational, physical and speech therapy

*Certain DME may be considered Custom DME due to its modification for use by a particular member. The term Custom DME shall mean equipment that is significantly altered or uniquely manufactured to meet the specific needs of an individual member according to the description and orders a physician or licensed practitioner whose license permits such practitioner to order Custom DME.

All codes billed other than the per diem revenue codes (0191-0194, 0199) will be denied as included in the per diems rates. If the referenced per diem revenue codes are not submitted on the claim, the claim will be denied. Exceptions include outliers, instances where Blue Plan coverage is secondary to Medicare and other specific instances defined in the member’s contract.

Participating SNFs can coordinate select medications with one of the pharmacy providers that are part of the SNF select medication program. These pharmacy providers will bill and be reimbursed directly for these services. Please refer to the Skilled Nursing Facility Select Medication Program section program details.

Any services not included in the per diem rate should be delivered and billed by participating providers outside the SNF. Contact Care Coordination for a list of participating providers for these services.

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Outpatient Payment Methodology

All SNF outpatient claims will process as follows:

  • Outpatient services will be reimbursed according to Florida Blue developed fee schedules.
  • Payment will be based on each covered unit identified by the applicable revenue and CPT/HCPCS codes (1 unit = 1 modality).

Note: Not all SNFs are contracted to provide outpatient services. See the applicable agreement for specific terms.

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7/16/2014
The Manual is not intended to be a complete statement of all BCBSF polices or procedures for providers. Other policies and procedures, not included in this Manual, may be posted on our website or published in special publications, including but not limited to, letters, bulletins, or newsletters. Any section of this Manual may be updated at any time. In the event of any inconsistency between information contained in this Manual and the agreement(s) between you or your facility and BCBSF or Health Options the terms of such agreement(s) shall govern.

The Manual is not intended to be a complete statement of all Florida Blue polices or procedures for providers. Other policies and procedures, not included in this Manual, may be posted on our website or published in special publications, including but not limited to, letters, bulletins, or newsletters. Any section of this Manual may be updated at any time. In the event of any inconsistency between information contained in this Manual and the agreement(s) between you or your facility and Florida Blue or Health Options the terms of such agreement(s) shall govern.

Refer to the References section to view all applicable copyrights, registered trademarks, service marks, and/or references. Acronyms are also defined in the References section.

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